Advanced Lung Disease and COPD: Worse in Winter, but Hospice Can Help
VITAS Healthcare - Pittsburgh
For more information about the author, click to view their website: https://www.vitas.com/locations-search/pittsburgh/cranberry-township-hospice-office
Mar 24, 2025
Pennsylvania - Greater Pittsburgh Area
By Henri Nammour, MD, Regional Medical
Director, VITAS Healthcare
Winter has arrived, and with winter comes lower
temperatures. The increased cold presents particular danger to people with
advanced lung disease (ALD) in general and chronic obstructive pulmonary
disease (COPD) in particular, leading to increased exacerbation frequency and
worsening of symptoms.
With the chronic and life-limiting nature of these
conditions, patients with ALD and COPD can benefit immensely from timely
palliative care and hospice referral and involvement.
Decreased Temperatures, Increased Exacerbations
Evidence in the literature shows the seasonality of COPD
exacerbations. A retrospective analysis of the large-scale TIOSPIR® trial
found “marked seasonal variation in COPD exacerbations, hospitalization, and
mortality.” The authors note that “in the northern hemisphere, the peak for
exacerbations is early winter, followed by the peak for hospitalizations in
midwinter.”15 An analysis of numerous COPD-related studies
worldwide saw a pattern of “clear seasonality in COPD [primary care]
consultations” and “increased hospital admissions for COPD exacerbations.”8
As the temperature drops, the rate of COPD exacerbations
increases. A study comparing meteorological variables with health system
registry data showed an inverse correlation between temperature and COPD
exacerbation rate.14
A Prevalent But Underdiagnosed Disease
In 2020, 12.5 million people reported a diagnosis of COPD,
chronic bronchitis, or emphysema.6 COPD is the fifth
disease-related cause of death.5 In 2019, there were close to
536,000 COPD hospitalizations and 1,320,000 COPD emergency department visits.4
These are staggering numbers, but COPD remains a disease
with under-reported prevalence and potential underdiagnosis; according to the
CDC, more than 50% of adults with low pulmonary function were not aware that
they had COPD.2
With early diagnosis and proper use of advance
care planning (ACP) and goals of care (GOC) discussion, the opportunity
to involve palliative care early on in the disease course and hospice
at the appropriate time can make a tremendous difference in
ALD/COPD patients’ and their families’ and caregivers’ lives.
An Opportunity for Improvement
Hospice is underutilized in ALD/COPD patients. While more
COPD patients are using hospice and palliative care, they are a small minority
of this large patient population. A significant proportion of patients with
COPD are not hospice users; consequently, they often receive a disproportionate
amount of aggressive interventions at the end of life.13
While there has been a general trend of increased use of
palliative care and hospice among COPD patients in the past two decades, “only
a minority of patients with COPD die at home or in hospice. Early PC
[palliative care] involvement in patients with severe COPD may improve the
end-of-life experience and increase hospice use.”16 A greater
proportion of decedents from pulmonary disease die in the hospital than
individuals dying of cancer, cardiovascular disease, cerebrovascular disease,
or dementia.7
For ALD/COPD patients, discussion of ACP and GOC are
typically provided too late, if at all. They were less likely to have advance
directives in place, leading to higher and more aggressive healthcare
utilization near end-of-life that offers little benefit in the face of advanced
disease.11
What Patients Want
Patients with advanced respiratory illness want to learn
more about end-of-life care. However, patients “report feeling frustrated by
poor communication and discussion surrounding ACP, and often feel that
important therapeutic and symptomatic goals are not discussed.”3
Notably and concerningly, fewer than one-third of patients
with COPD and their caregivers had even heard of palliative care. Only a
minority of these patients received formal palliative care referrals, and many
are only referred after ICU admission or prior to hospice initiation.7
ACP happens rarely in advanced lung disease, with only about
20% of patients engaging in these conversations on average and almost 30% of
these discussions occurring in the last three days of life.9 With
timely and appropriate discussion of ACP and GOC, patients were less likely to
receive unnecessarily intensive care towards end of life.11
Hospice and Palliative Care Improve Clinical Outcomes
When asked about their goals and needs, patients with
advanced illness desired controlling pain and symptoms, avoiding inappropriate
prolongation of the dying process, having a sense of control, relieving burdens
on family, and strengthening relationships with loved ones.
Greater utilization of hospice during the last 6 months of
life is associated with improved patient experience and clinical outcomes.10 Patients
with ALD and their families experience improved overall satisfaction with their
care, improved symptom control and quality of life, fewer unnecessary
procedures and interventions near the end of life and higher likelihood of
dying at home. Earlier hospice referral has even been associated with prolonged
survival.1
Hospice Cost Savings: A Matter of Dollars and Sense
Per a recent report from NORC, hospice provides
significant cost savings. The cost for Medicare beneficiaries who used hospice
was lower than the cost for those who did not use hospice, with a 20% lower
average total cost of care seen in beneficiaries with respiratory disease.12
NORC's findings show clear
quantitative cost-saving benefit with the use of hospice in
patients with respiratory diseases; however, the principal benefits of hospice
remain the improvements in quality of life and in patient, family, and
caregiver satisfaction.
Hospice Can Help
Hospice
alleviates symptom burden and improves quality of life for
patients suffering from ALD and COPD; it promotes goal-concordant care with
decreased readmissions, reduced in-hospital mortality, lower total costs of
care, and improvement in patient satisfaction.
Related: Hospice
Eligibility Guidelines for Patients with ALD/COPD
If your patient does not yet qualify for hospice, bringing
palliative care onboard early in the patient's disease course can help
facilitate advance
care planning and goals of care discussion, and ease a patient's
transition into hospice when
the time is right.
The prevalence of ALD in general and COPD in particular
means that there is a large patient population that is not currently taking
advantage of the myriad benefits that hospice can provide. There is ample
opportunity for hospice to improve the quality of life for millions of patients
and for their caregivers and loved ones.
1. Adler ED, Goldfinger JZ, Kalman J, Park ME, Meier DE.
Palliative care in the treatment of advanced heart failure. Circulation.
2009;120(25):2597-2606. doi:10.1161/circulationaha.109.869123
2. Basics about COPD. Centers for Disease Control and Prevention. June 30,
2023. https://www.cdc.gov/copd/basics-about.html.
3. Brown CE, Jecker NS, Curtis JR. Inadequate palliative care in chronic lung
disease. an issue of health care inequality. Annals of the American Thoracic
Society. 2016;13(3):311-316. doi:10.1513/annalsats.201510-666ps
4. COPD trends brief - burden. COPD Trends Brief - Burden | American Lung
Association.
https://www.lung.org/research/trends-in-lung-disease/copd-trends-brief/copd-burden.
5. COPD trends brief - mortality. COPD Trends Brief - Mortality | American Lung
Association.
https://www.lung.org/research/trends-in-lung-disease/copd-trends-brief/copd-mortality.
6. COPD trends brief - prevalence. COPD Trends Brief - Prevalence | American
Lung Association. https://www.lung.org/research/trends-in-lung-disease/copd-trends-brief/copd-prevalence.
7. Cross SH, Ely EW, Kavalieratos D, Tulsky JA, Warraich HJ. Place of death for
individuals with chronic lung disease. Chest. 2020;158(2):670-680.
doi:10.1016/j.chest.2020.02.062
8. Donaldson G, Wedzicha J. The causes and consequences of seasonal variation
in COPD exacerbations. International Journal of Chronic Obstructive Pulmonary
Disease. Published online 2014:1101. doi:10.2147/copd.s54475
9. Jabbarian LJ, Zwakman M, van der Heide A, et al. Advance care planning for
patients with chronic respiratory diseases: A systematic review of preferences
and practices. Thorax. 2017;73(3):222-230.
doi:10.1136/thoraxjnl-8552-147202
10. Kleinpell R, Vasilevskis EE, Fogg L, Ely EW. Exploring the Association of
Hospice Care on patient experience and outcomes of care. BMJ Supportive &
Palliative Care. 2016;9(1). doi:10.1136/bmjspcare-8552-147202
11. Lee RY, Curtis JR, Kross EK. Physician orders for life-sustaining treatment
and ICU admission near the end of life—reply. JAMA. 2020;324(6):608.
doi:10.1001/jama.2020.8654
12. NORC at the University of Chicago (2023). Value of Hospice in Medicare.
Available at:
https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf
13. Shen JJ, Ko E, Kim P, et al. Life-sustaining procedures, palliative care
consultation, and do-not resuscitate status in dying patients with COPD in US
hospitals. Journal of Palliative Care. 2018;33(3):159-166.
doi:10.1177/0825859718777375
14. Tseng C-M, Chen Y-T, Ou S-M, et al. The effect of cold temperature on
increased exacerbation of chronic obstructive pulmonary disease: A nationwide
study. PLoS ONE. 2013;8(3). doi:10.1371/journal.pone.0057066
15. Wise RA, Calverley PM, Carter K, Clerisme-Beaty E, Metzdorf N, Anzueto A.
Seasonal variations in exacerbations and deaths in patients with COPD during
the TIOSPIR® trial. International Journal of Chronic Obstructive Pulmonary
Disease. 2018;Volume 13:605-616. doi:10.2147/copd.s148393
16. Yaqoob ZJ, Al-Kindi SG, Zein JG. Trends and disparities in hospice use
among patients dying of COPD in the United States. Chest.
2017;151(5):1183-1184. doi:10.1016/j.chest.2017.02.030
- To view the original version of this article visit www.vitas.com/for-healthcare-professionals/making-the-rounds/2023/december/advanced-lung-disease-copd-worse-in-winter-hospice-can-help
- Seniors Blue Book was not involved in the creation of this content.
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For individuals in the Pittsburgh area seeking compassionate palliative or hospice care, VITAS Healthcare remains a premier choice, providing comfort, dignity, and unwavering support for both patients and their loved ones. Contact us today.